51177.1No. Street Lot No.
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CATION FOR PLUMBING PERMIT
CITY OF CUPERTINO
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1� Sanitary No.
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3(```)eFee S � J—n isf ,\4 inade to the City of Cupertino for a permit to install plumbing pipes
and/oSSe�k,ture'ss listed on the reverse side hereof, and agrees to install said prices and/or fixtures
o in 6rd2mce with the provisions of the Plumbing Code of the City of Cupertino, and all other
"E Iaws4pphcable thereto.
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Contractor, Agent
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StateLicense �Z O�'.� 2� Approved -62&047
C f/ Plumbing Inspector
FIXTURES
NUMBER
MAIN DRAIN
Units Fees
Units JFces
Water Heater
Size
Water Closet
Material
Bath Tub
To Curb
Shower
To Prop. Line
Lavatories
To Existing
Kitchen Sink
Not Conn.
Dish Washer
Waste Disposal
Wash Tray
STORM DRAINAGE
Washing Machine
Size
Water Softener
Material
Bar Sink
To Main Drain
Comb.Sink & Tray
To Curb
Dental Unit
Drinking Fountain
Floor Drain
WATER SYSTEM
Hopper
Size
Restaurant.Sink
Material
Sand Trap
TOTAL FEES
Urinal
Fixture Fee
Area Drain
Main Drain Fee
Water Leader
Storm Drain Fee
Sprinkler System
Water Sys. Fee
Relief Valve
GAq Fee, S,
Vac Breaker
Skimmer
Filter
Permit Fee Ch=i
Total
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Total Fee 'Ti